Early functional rehabilitation or cast immobilization for the postoperative management of acute Achilles tendon rupture? A meta-analysis of randomized controlled trials.
McCormack R and Bovard J. Br J Sports Med. 2015. [Epub Ahead of Print].
Take Home Message: A functional brace following surgery to repair an acute Achilles tendon rupture is safe and results in higher patient satisfaction than immobilization after surgery.
Acute Achilles tendon ruptures are becoming more common among physically active individuals. While cast immobilization following Achilles tendon rupture repair has been the standard of care, there is a growing interest in early post-operative motion with bracing and functional rehabilitation. If clinicians could gain a better understanding of the outcomes after both treatments, they may be able to optimize treatment outcomes and educate patients. Therefore, McCormack and colleagues completed a meta-analysis of randomized controlled trials to assess which postoperative treatment strategy is better. The authors completed an exhaustive literature search and identified 11 articles. Studies were included if they were randomized controlled trials comparing functional bracing and cast immobilization for the treatment of acute Achilles tendon rupture repair. The authors assessed each study for quality and risk of bias with the Downs and Black checklist. Studies were excluded if they did not meet a minimum score of 19 out of 27 points on the checklist. Overall, the 11 studies involved 570 patients (281 braced, 289 casted). All of these patients were treated for an acute Achilles tendon rupture. No re-ruptures were included. The authors found no difference between treatments with regards to either return to activity/employment or the rate of return to activity/employment. However, 5 of the 6 studies that measured rate of return to activity/employment noted that the bracing group returned to activity/employment faster than patients in the casting group but this was not statistically significant. Subjectively, patients in the bracing group were 3 times more likely to be satisfied with their outcomes following treatment than patients in the casting group. Finally, the 2 treatment groups did not differ with regards to the number of complications following treatment.
Overall, functional bracing following acute Achilles tendon rupture repair is as safe as cast immobilization. Furthermore, while functional bracing failed to offer faster return to activity/employment, patients treated with functional bracing reported being more satisfied. Therefore, functional bracing is safe and subjectively more effective than cast immobilization. Unfortunately, while all studies scored 19 or more points on the Down and Black checklist the authors offered little information about the quality of the individual studies. This information would help clinicians make a more informed decision and indicate if we need more studies. Until more information on study quality is reported the current meta-analysis suggests that clinicians can consider functional bracing as a viable treatment option for acute Achilles tendon rupture repair.
Questions for Discussion: Would you advocate for patients to be put in a functional brace after an acute Achilles tendon rupture repair? Considering that there is no difference between return to activity/employment, why would you advocate one over the other as a clinician in your current setting?
Written by: Kyle Harris
Reviewed by: Jeffrey Driban
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